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As a career path, early childhood mental health consultation (EC-

MHC) is an emerging and growing work force opportunity. In keeping with the vision of an effective and transformed service system expressed in the final report of the President’s New Freedom Commission, states and communities are expanding their capacity to meet the mental health needs of young children and their caregivers through mental health con-sultation. ECMHC supports children in naturalistic community settings, avoids the excessively “expert” atti-tude,9 and works through collabora-tion with families and other providers who care for them. In addition, there is growing experience and research evidence6 to suggest that ECMHC is an effective service that, from a pub-lic health perspective, promotes social and emotional development and pre-vents or reduces the impact of mental health problems in young children.

The early childhood mental health consultation workforce is in transition from one of broad diversity in terms of training, experience, roles, respon-sibilities, and work expectations to one that has specific expertise in early childhood mental health and the spe-cific skills required to take on the role of consultant. The purpose of this article is to support the development of a transformed workforce with the attitudes, knowledge, skills, and be-haviors to work as early childhood mental health consultants in a chang-ing children’s mental health field.

Defining ECMHC

ECMHC includes culturally sen-sitive and primarily indirect services for children birth- through- six in group care and early education settings. In-direct services include building capac-ity among staff and family members, observing children and the caregiving environment, and designing interven-tions that involve changes in the be-

haviors of caregivers. ECMH consul-tants collaborate with administrators, staff, family members, and caregiv-ers who intervene directly with chil-dren in group care, early education, and/or home settings. ECMHC is intended to promote social and emo-tional development in children and to transform children’s challenging behaviors. Two types of consultation are: (1) child- or family-centered con-sultation to address factors that con-tribute to a child’s (and/or family’s) difficulties in functioning well in the early childhood setting, and; (2) pro-grammatic consultation to improve the overall quality of the program or agency and/or assist the program to solve issues that affect more than one child, staff member, and/or family.3

Illustrative Scenario

Since moving to a new childcare classroom, Robert cries and disturbs other children during naptime. He

does not eat very much and does not seem to enjoy classroom activities. At Robert’s teacher’s request, the mental health consultant visits the center to observe Robert at various times dur-ing the course of a day. The consul-tant also assesses the quality of the interactions in the classroom between Robert and the other children. The consultant then meets with Robert’s parents and discovers that Robert’s mother’s new work schedule causes frequent disruptions in the family routine. The consultant helps both parents and child care staff to un-derstand Robert’s behavior and helps them develop new strategies at home and in the classroom so that Robert develops a sense of predictability. By observing and encouraging commu-nication between staff and parents, the consultant helps Robert’s caregiv-ers implement strategies to help him adjust to change (child- or family-cen-tered consultation). In addition, the staff improve how they transition the entire class from lunch to nap time and, as a team, respond to special needs of individual children (pro-grammatic consultation).

What is the Need?

There are a number of compelling reasons for supporting, training, and utilizing consultants. Perhaps most prominent of these is the growing number of very young children who are exhibiting social-emotional prob-lems and who are spending signifi-cant amounts of time in non-parental care in early childhood settings. Re-cent research suggests that expulsion rates for children in preschool far exceed expulsion rates for children in K-12.5,7 In a national survey of pre-kindergarten programs, Gilliam5 found that teachers who had access to an ECMH consultant were less likely to expel children than teachers who did not have a mental health pro-fessional available to them. ECMHC

Early Childhood Mental Health Consultation: A Developing Profession

Winter 2008, 22(1)

Regional Research Institute for Human Services, Portland State University. This article and others can be found at www.rtc.pdx.edu. For reprints or permission to reproduce articles at no charge, please contact the publications coordinator at 503.725.4175; fax 503.725.4180 or email rtcpubs@pdx.edu FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health

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may also decrease child care provider stress and high rates of job turnover by enhancing caregivers’ abilities to successfully manage difficult be-haviors and promote positive social-emotional development.1 Decreasing turnover also supports the continuity of care essential for children’s social-

emotional development. Further, it is important to note that ECMHC may help to identify and ameliorate chal-lenging behaviors before serious prob-lems emerge, thus reducing the need for more costly and specialized inter-vention services later in life. However, at this time, many early childhood educators do not have ready access to a mental health professional for infor-mation, resources, or support.5

Competencies and Preparation

At the core, consultants must have knowledge of child development, for-mal preparation in children’s mental health, and experience working with young children and their families. In order to assist early care and education staff with identifying and addressing atypical behaviors in young children, consultants need to have knowledge of and experience with child devel-opmental milestones, early childhood education and early intervention sys-tems.3,4 Consultants should have a strong foundation in early childhood mental health best practices, so they can: (1) support program directors and staff with developing a mental health program philosophy and a shared vision of mental health ser-vices, and; (2) help implement strate-

gies to promote social and emotional development and reduce challenging or troubling behavior.8 In addition, consultants should have knowledge of family systems and feel comfort-able working with parents of children enrolled in early childhood settings.3 Finally, consultants must have a deep

understanding of how cultural and linguistic diversity contribute to per-spectives on child development and child mental health.

In addition to these professional competencies, consultants must pos-sess the skills that enable them to work in collaboration with families and early care and education staff. Thus, consultants should be able to:

recognize and build upon the strengths of early childhood staff and families, thereby avoiding an “expert” stance;

use facilitation skills to encourage communication and interaction among early care and education staff and families;

employ coaching and modeling skills to encourage shared prob-lem solving; and,

become an integrated part of the early childhood program.

While consultants often enter the field of ECMHC with a strong foun-dation in mental health, some begin-ning consultants may lack knowledge and experience in early childhood and/or be unfamiliar with the consul-tative approach. Additional training, supervision, and support are needed to help them develop the range of skills and broad knowledge base

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that are necessary to be effective in the consultant role. A variety of ap-proaches currently exist for training and supporting consultants. Some states investing in ECMHC, such as Colorado, Michigan, and Ohio, of-fer systematic in-service training to early childhood and mental health professionals to prepare them to be consultants. A few well-established ECMHC programs, such as Day Care Consultants in San Francisco, CA, have created intensive pre-ser-vice training modules for all begin-ning consultants. Several colleges and universities, including Portland State University and Wayne State University, have begun to develop certificate or credentialing programs in early childhood mental health that include training specific to consulta-tion. Models for training consultants are in various stages of development, so research should focus on deter-mining the necessary components of training, supervision, and support for developing and maintaining effective consultants.

How Effective is ECMHC?

The evidence base is building for the effectiveness of ECMHC. Search-ing for published and unpublished research and evaluation studies, re-viewers found 28 studies that were reported in two recent research syn-theses addressing outcomes for chil-dren and families,10 and staff and pro-grams.2 One challenge of conducting these reviews was the absence of a clearly-defined consultation model in nearly all of the investigations.

Perry and her collaborators10 found that children in classrooms re-ceiving consultation generally showed more improvement in social and emotional development, and greater decreases in problem behavior, than did children in no-consultation com-parison groups. However, these re-viewers found that results for families were more mixed; while there was some evidence of improved parent-staff communication, greater access to mental health services, and more positive child-parent interactions with consultation services, no changes in parenting stress were detected.

Brennan and her review team2 found generally positive outcomes for

Winter 2008, 22(1)

Regional Research Institute for Human Services, Portland State University. This article and others can be found at www.rtc.pdx.edu. For reprints or permission to reproduce articles at no charge, please contact the publications coordinator at 503.725.4175; fax 503.725.4180 or email rtcpubs@pdx.edu FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health

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staff, with evidence that consultation improves their feelings of competency and effectiveness, and increases their attunement to the needs of children. Decreases in staff stress were found in several studies, but this finding was not replicated in a recent well-con-trolled study of consultation.6 Finally, programs were found to benefit from ECMHC in multiple studies that re-ported lower staff turnover and fewer children expelled for behavior.

What Comes Next?

Professionals trained in early childhood mental health are in in-creasingly greater demand. Simulta-neously, states are investing heavily in ECMHC as a promising interven-tion by creating funding initiatives using state general revenue dollars and through the creative use of fed-eral funding streams such as Medic-aid, TANF, special education, public health, maternal and child health, mental health, child welfare, and childcare block grants. An informal survey of states conducted by one of the authors found funding that ranged from $200,000 for several pilot sites to $5 million for a large, state-wide ef-fort. While most states still struggle with the difficulty of paying for EC-MHC without a designated “client,” a patchwork approach to funding has worked for some.

ECMHC is at the brink of becom-ing an evidence-based practice, but further evaluation and research are needed. Data are essential to inform the decisions that states, communi-ties and programs make about many aspects of ECMHC and workforce preparation. Such data can answer important questions such as:

Who is best suited to be an effec-tive consultant?

What education, competencies, skills, and ongoing training and supervision are needed?

What components of the model lead to the best outcomes?

What level of intensity and du-ration of ECMHC is required to achieve positive outcomes?

How do we measure the qualities that define a good relationship between the consultant and care-

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giver?

Are there disparities among the children being identified for inter-vention?

Do consultants have adequate cul-tural and linguistic competence to work in our diverse nation? And if not, how can we equip them with necessary knowledge and skills?

ECMHC is consistent with the transformation goals set by the New

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Freedom Commission and embraced by many state agencies. Reducing ex-pulsion from preschool, enhancing the skills of the early care and educa-tion workforce, and helping families grapple with the challenges of raising a temperamentally difficult child are all in a day’s work for early childhood mental health consultants. Let’s learn more about what makes this impor-tant role most effective.

For states, communities, agencies and programs investing in early childhood mental health consultation

and committed to quality data

This web-based resource combines a brief review of the literature and current research addressing the effectiveness of early childhood mental health consultation with guidance for designing and implementing pro-gram evaluation. It will help states, communities, and programs increase their capacity for high-quality evaluation of early childhood mental health consultation in community-based settings. Researchers, policy makers, and program evaluation teams will find:

A brief review of the evidence base, current issues, and questions;

Defining characteristics of early childhood mental health consultation;

Components of high quality evaluation and sample logic models;

Evaluation tools to measure both process and outcome, including outcomes for children, families, staff, and pro-grams; and

Guidance for using evaluation data for improving programs and communicating outcomes.

Developed collaboratively by:

Georgetown University, National Technical Assistance Center for Children’s Mental Health

http://gucchd.georgetown.edu/programs/ta_center/index.html

Johns Hopkins University, Women’s and Children’s Health Policy Center

http://www.jhsph.edu/wchpc/

Portland State University, Research and Training Center on Family Support and Children’s Mental Health

http://www.rtc.pdx.edu/

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EARLY CHILDHOOD MENTAL HEALTH CONSULTATION: AN EVALUATION TOOL KIT

The Toolkit is available at:

http://www.rtc.pdx.edu/pgECMHCToolKit.shtml

Winter 2008, 22(1)

Regional Research Institute for Human Services, Portland State University. This article and others can be found at www.rtc.pdx.edu. For reprints or permission to reproduce articles at no charge, please contact the publications coordinator at 503.725.4175; fax 503.725.4180 or email rtcpubs@pdx.edu FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health

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References

Alkon, A., Ramler, M., & MacLennan, K. (2003). EvaluationEvaluation of mental health consultation in child care centers. Early Childhood Education Journal, 31(2), 91-99.

Brennan, E. M., Bradley, J. R., Al-len, M. D., & Perry, D. (2007). The evidence base for mental health con-sultation in early childhood settings: Research synthesis addressing staff and program outcomes. Manuscript submitted for publication.

Cohen, E., & Kaufmann, R. (2005). Early childhood mental health consultation. Promotion of mental health and prevention of mental and behavioral disorders (Vol. 1). Wash-

ington, DC: U. S. Department of Health and Human Services, Sub-stance Abuse and Mental Health Services Administration, Center for Mental Health Services.

Collins, R. C., Mascia, J. L., Ken-dall, R., Golden, O., Schock, L., & Parlakian, R. (2003). Promot-ing mental health in child care set-tings: Caring for the whole child. Zero to Three, 23(4), 39-45.

Gilliam, W. S. (2005). Prekinder-garteners left behind: Expulsion rates in state prekindergarten systems. New Haven, CT: Yale University, Child Study Center.

Gilliam, W. S. (2007). Early child-

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hood consultation partnership: Results of a random-controlled evaluation. New Haven, CT: Yale University, Child Study Center.

Gilliam, W. S., & Shahar, G. (2006). Prekindergarten expulsion and suspension: Rates and predic-tors in one state. Infants and Young Children, 19, 228-245.

Green, B. L., Simpson, J., Ever-hart, M. C., Vale, E., & Gettman, M. G. (2004). Understanding in-tegrated mental health services in Head Start: Staff perspectives on mental health consultation. NHSA Dialog, 7(1), 35-60.

Johnston, K., & Brinamen, C. (2006). Mental health consultation in child care: Transforming relationships among directors, staff, and families. Washington, DC: Zero to Three.

Perry, D. F., Allen, M. D., Bren-nan, E. M., & Bradley, J. R. (2007). The evidence base for mental health consultation in early childhood settings: Research synthesis addressing child and family outcomes. Unpub-lished manuscript, Johns Hopkins University.

Authors*

Mary Dallas Allen is a doctoral student in the School of Social Work at Portland State University.

Eileen M. Brennan is Professor and Associate Dean of Social Work, and Co-Principal Investigator with the Research and Training Center on Family Support and Children’s Men-tal Health at Portland State Univer-sity.

Beth L. Green is Vice President of NPC Research, a human services research and evaluation company.

Kathy S. Hepburn is a private consultant and affiliate faculty at Georgetown University National TA Center for Children’s Mental Health.

Roxane K. Kaufmann is Di-rector of Early Childhood Policy at the Georgetown University National Technical Assistance Center for Chil-dren’s Mental Health.

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2007 STAFF of the RESEARCH AND

TRAINING CENTER ON FAMILY SUPPORT AND CHILDREN’S

MENTAL HEALTH

Regional Research Institute for Human Services

Graduate School of Social WorkPortland State University

PO Box 751 Portland, OR 97207-0751

Voice: 503.�25.4040Fax: 503.725.4180www.rtc.pdx.edu

Barbara J. Friesen, Director; Janet S. Walker, Director of Research and Dis-semination; Donna Fleming, Center Co-ordinator; Nicole Aue and Ariel Holman, Project Support; Cintia Mason, Student Assistant.

Voices of Youth: Pauline Jivanjee and Jean Kruzich, Co-Principal Investiga-tors.

Transition to Independence: Pauline Jivanjee, Principal Investigator; Nancy Koroloff, Project Consultant; Mandy Da-vis, Senior Research Assistant.

Achieve My Plan: Janet S. Walker and Laurie Powers, Co-Principal Investiga-tors; Barbara J. Friesen and Jean Kru-zich, Project Collaborators; Rujuta Ga-onkar, Research Associate; Jonathan Melvin and Elizabeth Thorne, Student Research Assistants; Jane Woodin, Practicum Student Research Assistant. Work-Life Integration: Julie Rosenzweig and Eileen Brennan, Co-Principal Inves-tigators; Anna Malsch, Project Manager; Lisa Stewart, Graduate Research Assis-tant; John Conley, Student Mentee.

Transforming Transitions: Beth Green, Principal Investigator; Anna Malsch, Project Manager; Eileen Brennan, Proj-ect Collaborator; Brianne Hood, Gradu-ate Research Assistant; Jessica Green, Student Research Assistant.

Practice-Based Evidence: Barbara J. Friesen and Terry Cross, Co-Principal Investigators; L. Kris Gowen, Research Associate; Pauline Jivanjee and Janet Walker, Project Collaborators; Pachida Lo, Student Mentee.

Underrepresented Researchers Mentor-ing Program: Anna Malsch, Project Co-ordinator; John Conley and Pachida Lo, Student Mentees.

Learning Community: Barbara Friesen and Harold Briggs, Co-Principal Inves-tigators; L. Kris Gowen, Research As-sociate.

Building on Family Strengths Confer-ence: Donna Fleming, Anna Malsh, Pauline Jivanjee, Rujuta Gaonkar, Ariel Holman, and Nicole Aue, Conference Planners.

Publications: Nicole Aue and Ariel Hol-man, Publications Coordinators; Cintia Mason, Publications Assistant.

We invite our audience to submit letters and comments:

Janet S. Walker, Editor: janetw@pdx.edu

Publications Coordinators: rtcpubs@pdx.edu

*Authors listed in alphabetical order

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Regional Research Institute for Human Services, Portland State University. This article and others can be found at www.rtc.pdx.edu. For reprints or permission to reproduce articles at no charge, please contact the publications coordinator at 503.725.4175; fax 503.725.4180 or email rtcpubs@pdx.edu FOCAL POiNT Research, Policy, and Practice in Children’s Mental Health